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Chapter 33 (page 170)
Case 33.13 G.T., 58 year old female. Radiology: 8.0 cm long nodular, constricting
filling defect pyloric region. Base of duodenal bulb normal. Operation: large tumor
mass with serosal extension and lymph node metastases. Billroth II. Gastric histology:
mucinous adenocarcinoma extending through all layers of gastric wall. Duodenal
histology: spread into first 2.0 cm of duodenal serosa, muscularis, submucosa and
mucosa. No comment on Brunner's glands.
Case 33.14 A.A., 39 year old female. Radiology: ulcerated pyloric filling defect.
Base of duodenal bulb normal. Operation: fungating pyloric mass with serosal extension
and lymph node metastases. Duodenum appears normal. Billroth II. Gastric histology:
poorly differentiated adenocarcinoma with signet ring cells. Duodenal histology: spread
into duodenal mucosa for distance of 5.0 cm. Brunner's glands free of tumor cells.
As far as the histologic evaluation of duodenal spread of pyloric adenocarcinoma is
concerned, it should be kept in mind that resections were not performed in cases with
very extensive disease; in these cases specimens were not available for examination, and
the extent of duodenal spread remains undetermined.
A striking feature in the 7 cases with microscopic evidence of duodenal spread is the fact
that spread occurred for very short distances. In 3 cases it involved not more than the
proximal 2.0 cm of the duodenum; in one it was found to extend to the commencement
of Brunner's glands. In 2 cases the extent of spread was not mentioned, but judging by
the descriptions it appeared to be very short; only in one case did spread extend into the
duodenum for a distance of 5.0 cm.
Duodenal Spread in Relation to Gastric and Extragastric Extension
All 7 cases with microscopic evidence of duodenal spread had serosal involvement on the
gastric side with extragastric extension to draining lymph nodes; one of the cases also
had extension to the transverse mesocolon and spleen.
Most of the 16 cases without microscopic evidence of duodenal spread had widespread
gastric and extragastric extension, e.g. to the serosa, omenta, draining lymph glands, liver
Radiography is highly sensitive and specific in the diagnosis of pyloric adenocarcinoma.
In the present series of 50 cases the diagnosis was confirmed by endoscopy and/or
operation in all. In only one case was a differential diagnosis considered; in this
exceptional case the lesion had to be differentiated from malignant lymphoma (Chap. 34),
cicatrization and obstruction due to benign pyloric ulceration (Chap. 29), acid corrosive
stricture (Chap. 39) and eosinophilic infiltration. Malignant processes with rather
different radiographic appearances are Carman ulcer, linitus plastica and early gastric
carcinoma. Radiography also plays a useful role in the assessment of individual cases, as
the state of the pyloric aperture and other features not readily visible endoscopically, may
It is surmized that destruction of the various anatomical constituents of the pyloric
sphincteric cylinder, seen radiographically in all 50 cases, with associated lack of cyclical
contraction and relaxation of the cylinder, will result in absent or severely impaired
propulsion and trituration of solids (Chap. 18). Mucosal destruction and consequent lack
of mucosal fold movements should aggravate these effects (Chap. 13).
Radiography shows that in the absence of actual obstruction, i.e. in the majority of cases,
emptying of liquid barium is not usually delayed to an appreciable extent.
Radiography is less accurate as far as evaluation of the duodenum in cases of pyloric
adenocarcinoma is concerned. However, the smooth and regular appearance of the base
of the duodenal bulb, seen in 40 of the 50 cases, is of importance. This "normal"
appearance, seen in association with a constant filling defect involving the pyloric
sphincteric cylinder, is corroborative evidence of pyloric carcinoma. The same holds true
for smooth, concave indentations of the base of the bulb; this appearance, seen in 4
cases, is presumably due to external indentation by the pyloric tumor. In conditions such
as malignant lymphoma, eosinophilic granuloma, corrosive stricture and tuberculosis, the
duodenal bulb is usually deformed. Even in the presence of histologically proven
duodenal spread, the duodenum may appear normal radiologically. In 20 cases of
transpyloric extension, Koehler et al. (l977) noted duodenal abnormalities in 6, 14
appearing normal. In our 7 cases with microscopic spread duodenal abnormalities were
seen in 2 only.
Macroscopically, at operation, duodenal spread may not be evident (Castleman l936;
Paramanandhan l967). In 3 of our 7 cases the duodenum was considered to be normal at
operation. In one duodenal spread was noted; in 3 the condition of the duodenum was
not commented on.
The only unequivocal evidence of duodenal spread of pyloric adenocarcinoma is obtained
by microscopic examination (Castleman l936). In the following cases microscopic
duodenal spread of pyloric carcinoma was present in all:
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